>> Hi class, I hope you are doing well today. I am in Kunshan, China, with my friend and colleague, Dr. Bill Pan. Dr. Pan is a professor at Duke Lovell Health Institute, and he is also a professor in the Nicholas School of the Environment in Duke. Dr Pan's done work all over the world, everywhere from Asia to South America, and he specializes in works and relationship between health, population change, and the environment. So I thought it would be a beautiful place to sit down and have a little discussion about these topics and why they are important. Okay with you? >> Great, looking forward to it. >> All right, so first, can I just push you in one time? >> [LAUGH] No. >> How are we going to get over? >> We'll jump. >> All right- >> Big step, big step. >> Excellent, all right, kids, don't try this at home. [LAUGH] All right, let's have a seat. Bill, a lot of times when people think about global health, they think about humans, right? Human, biological issues. They don't necessarily think that there could be a relationship between human health and various other factors such as population change of the world around us. Now, I know that you're one of the people working to dispel this notion. So I'd love it if you would just take a few minutes and talk to the students about why this interaction is so important, and what impact it has on human health. Yeah, sure, so it's very common for people to have a very anthropocentric view of the world, because we're people. So anything that we are doing will ultimately affect ourselves. And so when you think about global health everyone thinks about people first. The problem is that whenever you change a landscape, you drive your car, or you plug your computer into the wall, or you fly an airplane, you're affecting something in the environment. And so you have to always think about those changes in the environment you have to adjust to as well. But not only yourself, but the plants, the animals, the insects, all the creatures on earth are adjusting to the changes that we make. We as humans produce the biggest changes to the environment, mostly through agriculture, urbanization, other kind of things about economic development. And these changes really affect the way other species live. And there is a very close relationship between how the health of other species is related to the health of humans, so we always have to think about that. And it's not just in tropical environments, where you think about very infectious diseases like Ebola, which is a big one. >> Of course, yes. >> But it can be very simple, like having a dog at your house. Your dog interacts with the environment much differently than the way we interact with the environment. >> I hadn't thought about that. >> So that they can in some ways introduce different diseases to your home that you wouldn't normally think about. >> Right, right, right, and yeah, I remember reading somewhere that actually dogs can get strep throat and it can be constantly passed between children and dogs. Could you give us a couple of examples of this issue, perhaps using some of the research that you're doing in South America? >> Sure, well, let me give you one example, just to connect to home a little bit more easily. >> Good, okay. >> So there are lots of studies on pet ownership and there's these relationships of how pets often get ill before humans. >> So there's lots of case studies, for example in Connecticut, where dogs would have an unknown illness, they have a rash, they start getting lethargic. And a pet owner, and I forget the name of the woman, but she brought the pet to the vet. The vet did various tests on the animal, trying to figure out what was going on, they couldn't quite figure it out. The pet kept on getting lethargic and ill, wasn't eating, was getting emaciated, and eventually the dog died. And about four or five days later, the woman started getting the same symptoms. She was getting fever, lethargic, she couldn't eat as well, and the vet, just by chance, did an autopsy on the dog and found out that the dog had Rocky Mountain spotted fever. They had tested it for lots of things. >> Really? >> So the vet, by chance, and it was only because the vet knew the MD that the woman was going to call, her physician, and said we tested the dog positive for Rocky Mountain spotted fever. They did the test on the woman right away, that's what it was, and she was treated, and she was fine. >> No kidding, so- >> So there's this relationship between humans and animals, and we can't forget this. In the Amazon, my research deals with vector borne diseases. We look at how toxicology, things like gold mining can affect mercury in the environment and increases the amount of mercury you can be be exposed to through bioaccumulation of mercury in fish. So mercury is a very broad example because it can have a lot of impact on ourselves. Not just having toxicity, but it affects our immune response, it affects our heart functioning, and it can affect the absorption of nutrition, so specifically iron, vitamin A, folate, vitamin B. All these things are affected by mercury. >> And these are all examples of common micronutrient deficiencies that have physical and cognitive impact on children. >> So one of the things we see in our studies is we have one of the highest anemia rates in the Amazon. And the area is not poor, but about 48 to 55% of children under 10 are severely anemic. But these are not kids that are malnourished. They're not stunted, they're not wasted. There's actually about, 15% are obese, but they're anemic. >> And anemic as well. >> So then the question is why are they not getting iron? They have a fish diet, they eat meat, they have a lot of peanut type foods in their diet. And so our kind of hypothesis is that they're getting very low chronic exposure to mercury because they eat fish, but it's not at a high level that would set off alarms. But it is a high enough level that prevents absorption of iron. And that very simple low exposure can cause massive effects as they grow older. So if they're anemic, eventually they will have cognitive impairments. >> Sure. >> They will probably eventually become stunted as they hit their teen years because they're not going to reach their full potential. And it just puts a It's handicap on a population. >> Sure, sure, and I would say also especially with, Girls as well, they grew up. So there's many issues with anemia on women in many parts of the world as well. I wonder if some of the implications of your work would be to look at other parts of the world where there are a lot of issues with, Industry, manufacturing, or other things where there might be a lot of mercury. And see if you have women and children in particular, women who are anemic, where there's more anemia in those areas surrounding as well. It's interesting how this could translate eventually from one area to, The other as well. >> The gold mining example, gold mining and mercury is probably isolated to areas that there is a lot of natural resource extraction. I would say a more general example, especially in developing countries, is agricultural production. So a lot of the theory on population environment deals with this idea that you start out as a subsistence farmer. And this is a household that is a nuclear household, husband, wife. They might have a child. In almost all situations the man is the one that is the head of the household. The woman more than likely does not have more than a primary education. And because they are subsistence farmers usually what happens is they don't have access to a large labor pool to help survive on the farm. So the only way to get labor is to have more children. And if the woman is put pressure to have more children that means she will have less opportunity to get education. Less opportunity to get other kind of technical skills that might also contribute to the family's income. But it puts her into this vicious cycle where she's reproducing and having lots of children. And she never quite gets herself out of poverty because most of the evidence suggests that once families make this decision of having more children they don't break out of poverty. It actually puts them into deeper poverty. And so we really need to work on this idea, or erase this idea that more children are better for survival. You really need to just invest in the children that you have. Invest in the female education. And make sure that the other sex in humans is actually as empowered as males are. >> Sure, sure, sure, and I guess that is going to be an increasing issue- >> Huge issue. >> In the world. Yes, absolutely. So in class we talk a lot about, Determinants of health both proximal and distal. And we talk about the web of causation and how all, so many determinants interact in multiple ways. And it seems to me that your work, which ranges from looking at the toxicological all the way to issues of education and gender inequity are a really good example of that. Now do you see that is, as we know with the issues of climate change we're going to see not only humans having an impact on the world that the world's going to start looking a little bit different as well. And what role do you think that climate change is going to have on health and just on movement and how populations look? >> So that’s a very tough question [LAUGH]. >> I’m good at that, yes. >> So no one really honestly knows how climate change is going to affect health. Most of the impact from climate change is based on scenarios and models that, we know how to link climate variability with vector-borne diseases. So a lot of the evidence suggests that things like malaria, dengue and now chikungunya and other not just vector-borne but zoonotic diseases that are spread by animals will likely increase because you're going to have a bigger interface between people and those environments. The one thing that I think that is likely not well understood, not for the future and not for our history, is how people will move. And migration I think is something that is a response to climate change, but it's also something that is not well understood at all. So I'm trained also in demography, demographers generally study international migration. The problem with climate change is that you will likely not only have international migration but you're going to have a lot of Internal migration. Internal migration is something that can be temporary, can be permanent. Either way we don't know where people move with their countries very well. That data doesn't exist. Determinants of international migration, yes, we know that as a science pretty well. But when you talk about how movement affects health international migration is kind of like I'm getting out of this situation, moving to an entirely new country with a different set of social standards. A different type of infrastructure that can give me support. So that's different. But if you're moving within country, you're staying within the same support mechanism, you're likely still exposed to the same environment. And you're still trying to keep your tie to your home. In that sense your risks for poor health outcomes, I think, is higher. Because you're trying to hold onto what you had as well as adjust to the new within your same country which will be easier in some ways. Like in our data that we look at migration and specifically malaria and dengue we actually see the people who are temporary labor migrants or people who are migrating because of the flood in their home, they are at greatest risk for disease. It's not just malaria, it's diarrhea, malnutrition, you name it, they're at greater risk for it. People who have more resilience to changes are obviously better off. >> Sure, right, right, right, and I was thinking when you were talking about that with countries like, I don't know, Bangladesh, there are so many people along the coast. If people end up migrating and have to migrate in there can also be, as a population moves to a smaller space or changes to exactly where they are, there can be other things. Increased competition for food, water, maybe even more change in how the land looks. And again, I would say we have known unknowns and unknown unknowns, right? That may be an unknown unknown. >> So it's funny. >> I was teaching a course this summer on sea level rise and the impact on human health. And one of the things we looked at were the number of people who lived five meters above sea level and ten meters above sea level. And I can't remember the exact number but it was something like I want to say 150 million people globally in five meters or less above sea level. More than likely all those people will be displaced, And Bangladesh is one of the main countries, there's a lot areas around Egypt. Surprisingly Germany is going to be having it [CROSSTALK]. >> Germany? >> You look at one of the main, I think it's the road that comes out of Germany, the road is very low level. >> I did not know that actually. >> If get a four meter rise in sea levels, the flooding goes all the way to Hamburg, which is 100 kilometers inland. And it's amazing. Actually, yeah. So when you talk about climate change and improvement, it's not just the poor countries that are going to be impacted. It's an everybody issue. >> Great example of sort of being [INAUDIBLE] really what global means, right? Global is not just the global south, and I assume even the East Coast of the United States will be impacted as well, right? I don't know, we live indoors, maybe we'll have beach front property. Probably not. >> Although North Carolina's got its own problem. The legislature, I don't know if you want to talk politics. >> Please talk away. >> Legislature, they actually got rid of all the scenarios for future climate change. And they're requiring the predictions of climate change for North Carolina and for planning only to go out, I think it's a ten year scenario. So they only want to plan out ten, maybe it's 15 years, I forget the cut off. But it's a ridiculously short amount of time, but the belief is that, I think the belief among the Republican legislature, is that we don't have to plan out 50 years in advance. We can plan as we go. >> I see. >> I don't know, but my opinion is that's not a smart thing to do, but different states are taking different strategies. New York and New Jersey are much more progressive. >> I see. >> [INAUDIBLE] than we are. >> Well, that's actually- >> [LAUGH] >> A good example that I taught. I talk with the students a lot about data, the uses of data, how data can be used, how it can be misused, how data can be aggregated to the extent that it obfuscates lots of issues that might affect say vulnerable populations or particular groups. But another point is that intentionally not collecting data, not making predictions, you can also obfuscate. Do not have to deal with things, I don't know if you remember the big cholera outbreak in South America, right? In the early 1990s, and Venezuela, of course, was really worried about tourism at the time. So, one of the things that happened is that they were, it was one point in the crisis when it was really hitting the indigenous populations that you could not, nothing was counted as cholera unless there was confirming tests, laboratory tests. But the ministry refused to send any equipment to do the test, so cholera rates dropped, right? I mean, these are the stories that just go again and again and again and again, global north, global south, exactly. I also know just from talking with you, hanging out with you, drinking with you that you were also very interesting. >> Don't drink. >> Don't drink, don't drink, kids. >> [LAUGH] >> Save it for us, okay? That you were very interested and actively involved in the issue of translational or translation medicine, translation science. This is a term students hear a lot, and I wonder if you would explain exactly what that is, why it's important, and give us some examples. I know I ask these- >> Translational meds. >> Translational meds. >> Or translational research? >> Both. >> I think everyone has their own definition of what translational research means. >> I see. >> I mean, to me, I kind of feel like translational research just means something that you can directly apply to policy. >> Ah-ha, okay. >> And I feel like kind of like the word global health versus public health, translational research and translational medicine is the way to give more money for things that we've already been doing. >> Aha, right. >> Which is trying to evoke policy to promote public health and to promote human welfare and environmental welfare. So in my own examples, for example, we are trying to produce very simple tools for people improving Amazon to choose fish that they can consume that are safe. >> A-ha, right. >> So very simple codes on pictures of carnivorous versus non-carnivorous fish, which we clearly show in some of our papers that the carnivorous fish are extremely toxic in terms of being exposed to mercury where as the non- carnivorous ones have a much lower probability of exposing you to mercury. So in a way, I view that as translational research. We work with the Ministry of Health, we help produce some of the posters that they're using to advertise and help host and to give out to families. And so I think that's kind of how I feel. >> Sure. >> That's what I think of translational research. >> Right, that makes a lot of sense because it's translatory, it's from one place to the other, it's like the shift that we talk a lot about in public health instead of health research, right? We do research for health, we always want to take what we learn, take the research, get it on the ground, see if it can work, get it to work, and scale it out. But I like the example that you just gave about how effective something as simple as having photographs and codes, it can be. Because also when we think about doing things on the ground, we think about improving global health. We think a lot about technology and innovation. But not all innovation is high tech, right? I tell the students we need to absolutely innovate, but also have better utilization of things that we already know. And you just gave a really, really [CROSSTALK] example. Yeah. >> Innovation doesn't have to require a new technology. >> Right, yeah, right, right, right, right, always. >> And especially, you need to come up with innovations that are technology free because most of the people that we've worked with overseas in poor countries don't have it. >> Exactly. >> And they can't get access. >> Right. >> You need to make simple, I guess old school solutions from when you were young on communicating ideas. >> [LAUGH] >> [LAUGH] >> Just rub it in, I'm older than you are, rub it in, okay. >> [LAUGH] >> After the video, I drowning him in the lake, just letting you know that. >> [LAUGH] >> No, it's true, right? So yeah, so those old floppy disks and eight tracks I used to use probably won't have any role in the future. >> [LAUGH] >> Yeah, it's really interesting. Now you mentioned a couple of other things. You mentioned chicken which now of course is in the Caribbean. I remember we talked about malarative I don't know if you mentioned dengue or not, but I remember in the early 80s, there was not a dengue problem in Latin America. There was a lot of Chagas, but not so much dengue, pretty much been brought under control, and now it seems that it's spread almost everywhere as well. >> Yeah. >> How did that come about? And is the story of that so it made it to your work in different ways? >> It is, so one of the things that has happened over the past, I'd say 20 years in Latin America especially is the rapid rate of urbanization. So prior to 1990, there was only, I think, two cities in the Amazon that had over a million people. By 1995, I think there were four, by 2000, I think there were seven. And now, the Brazilian Amazon Is, I think it's 70% urbanized. >> I actually did not realize that. >> I should say, that's a wrong statement. I should say 70% of the population live in an urban area. >> In an urban area, okay, got it. >> That's a better way to say it. Whereas in Peru you still have, maybe it's closer to 40% urbanization. In Ecuador, also, maybe it's closer to 35%, but the rates are going up and up. Dengue is spread by aedes aegypti. Aedes aegypti is a urban mosquito. It exists in your back yard, tires, flower pots. It's associated with human construction. >> Right. >> And you can actually see as, for example, in in Peru or in where I'm currently working, you can actually see the clear trend of increasing human population density or size with the incidents of dengue. With more people obviously and more cases, but now that you get even more people living in Quidos, you have these cycles that occur every couple of years where you have these enormous outbreaks where 60,000 people will be diagnosed with dengue. Then it kind of goes away or fluctuates where you'll get 10,000 to 20,000. Then you get this jump again, in Porto where we work and we're based now, before 2004, there was zero dengue cases. >> Zero? >> Zero cases, 2005, they had about 15 cases, most of them were imported obviously from Brazil. But the thing that happened was in 2005, they began construction of the Interoceanic Highway. And so you had more migrant workers coming in to help build the roads. That construction went on from 2005 to 2011. And the case rates for dengue went from 20 people in 2005 to 100 people by 2007 to 500 people by 2010, and now it's over 5,000 people- >> Goodness. >> That are getting diagnosed with dengue in the past year. And so the rates, they're going up exponentially and
